Volume IX Special Issue 4- 2014

It was a privilege and an exciting opportunity for PATA to have attended the 20th International AIDS conference in Melbourne, Australia from 20-25 July 2014. Here are a few reflections and key highlights for the PATA network!

Prior to the start of the main conference, we attended the children’s pre-symposium, entitled “Start Early, Start now”, which was organised by the Coalition for Children affected by AIDS (CCABA) and the Teresa Group from 18-19 July where PATA delivered a presentation entitled “Integrating early childhood development (ECD) programmes into the paediatric HIV treatment response: Community health worker programmes in sub-Saharan Africa at the forefront”.

The pre-symposium provided a much-needed focus on children living with HIV, and understandably has grown in size over the years out of concern that these children are overlooked in bigger forums and conferences. As a smaller, more engaged and focussed conference, the pre-symposium offered an opportune setting to meet and connect with many PATA friends and colleagues, and provided an effective learning platform given the wide array of presentations on offer. The Melbourne Statement on Young Children Born into HIV-affected Families was launched at the children’s symposium and stressed the importance of investing in the early years. Starting early with the right interventions at the right time lays the foundation for children to thrive, saves money and mitigates the effects of HIV in the longer term. As children affected by HIV may experience developmental delays, there is greater necessity to focus on the earliest years of a child’s life, from birth to five years of age. Currently only 39% of HIV-exposed children are tested for HIV within two months of birth, and therefore more action and effort must be taken to integrate early infant testing and diagnosis into all MNCH services to ensure undiagnosed children are identified as early as possible and linked to treatment and care services.

Critically important for PATA in the Melbourne Statement was the call to integrate HIV programmes by building connections between health facilities and communities to provide more comprehensive support. Clinic teams should consider how to better integrate and link services such that each clinic visit becomes an opportunity to identify, assess and facilitate access to a package of services, as well as provide the necessary referral/s to allied support services where and when required. For example, programmes preventing mother-to-child transmission are linking mother-child pairs with early years support, ensuring healthy pregnancies and foetal development, and reducing loss to follow-up. Paediatric ART programmes can connect with a range of interventions to enrich the support that children are receiving, including linking to crucial community-based early learning, care and support programmes. Likewise, supporting and engaging with ECD, health promotion and nutrition programmes within communities can assist in providing key entry points to identify HIV-exposed children and link them to health services. The broader health system, through the provision of MNCH services, can establish linkages as well as expand their reach to offer non-clinical services such as parenting support as well as guidance on early learning and cognitive development of young children.

Highlights and key take-home messages from the children’s symposium for the PATA network:

Identify entry points to reach affected children from pre-natal to age six

Support caregivers and identify other siblings in the household for care and support

Provide opportunities to address parenting and ECD as part of MNCH services

Use both clinic and home visits to address multiple health and development issues

20th International AIDS Conference: Stepping up the Pace, Melbourne, Australia, July 20-25, 2014

The 20th International AIDS conference in Melbourne entitled “Stepping up the Pace” was premised on the ending of the epidemic as a public health threat by 2030 as a definable and realistic goal. Michel Sidibé, Executive Director of UNAIDS, together with various development leaders argued that ending the AIDS epidemic can be achieved by focusing efforts on where the epidemic is located and through a rights-based prism that challenges the socio-economic determinants of the epidemic and leaves no one behind.

Sadly the conference was overshadowed by the very tragic loss of conference delegates who were aboard the ill-fated Malaysia Airlines flight MH17 that was shot down in eastern Ukraine. Amongst the delegates on flight was the leading Dutch researcher and former president of the International AIDS Society, Joep Lange as well as respected activists from AIDS Fonds and Stop AIDS Now. Our heartfelt PATA condolences and sympathies are extended to their families and colleagues. They will be sorely missed.

Highlights and key take-home messages from AIDS 2014 for the PATA network:

Paediatric HIV:

Bill Clinton from Clinton Health Access Initiative (CHAI) highlighted the elimination of mother-to-child transmission (eMTCT) as one of the most exciting goals in public health as it is entirely achievable, and essential to achieving an AIDS-free generation. Amidst the huge strides that eMTCT has made to support this goal, the Global Burden of Disease Study published in The Lancet reported that whilst global childhood mortality (under 5 years of age) has reduced since 1990, deaths due to HIV/AIDS among children have actually increased and progress made over the past decade in increasing access to ART is not sufficiently reaching children. An estimated 3.3 million children currently live with HIV, but only about one third of those in need of treatment receive it, compared with over half for adults. Without treatment, more than half of HIV-positive children will die before they turn two years of age, and 80% will die before the age of 5 years. Early infant diagnosis (EID) and treatment of infants with HIV is therefore an urgent public health priority.

The World Health Organisation´s (WHO) 2013 consolidated HIV guidelines recommend immediate ART for all children under 5 years, yet this is not operational in many areas and will require setting targets, scaling up coverage and securing the necessary political will and policy changes that can reach and keep more pregnant mothers and their children in antenatal, post-natal, and longer-term HIV and MNCH care. Also, current rapid tests do not detect HIV in infants and very young children, with laboratory requirements for EID causing turnaround delays and limiting early result access in resource-limited settings. Point-of-care EID tests that can rapidly diagnose HIV in primary health care centres at local level is urgently required. Added to this are the challenges around securing the most appropriate medicines for children, as many available ARV formulations taste unpleasant, are difficult to store and transport, require refrigeration, have complex dosing requirements and have undesirable interactions with tuberculosis drugs. Added to this, current ARV formulations do not always meet the new WHO guidelines recommending the use of protease inhibitor-based first-line regimens for all children under 3 years of age.

PATA contributed to the Paediatric HIV Treatment Initiative (PHTI) satellite meeting, providing a short overview on key challenges and recommendations from frontline health workers on paediatric ART during the panel discussion. The PHTI has been instrumental in improving access to appropriate and affordable formulations, specifically fixed-dose combinations (FDCs) that assist in meeting paediatric treatment guidelines and provide for simplified treatment and greater retention in care. PATA welcomes the initiative between the Medicines Patent Pool (MPP), Drugs for Neglected Diseases Initiative (DNDI) and UNITAID and looks forward to new developments that will see more 4-in-1 ARV FDCs (LPV/r/AZT/3TC and LPV/r/ABC/3TC) designed specifically for children. These formulations will be in the form of taste-masked granules that can be mixed with food or drink, with easy dosing for caregivers and healthcare workers, and requiring no refrigeration. To counteract the interaction with TB drugs, a stand-alone ritonavir granule formulation is also in development.

The voices of people living with HIV (PLHIV), with a focus on youth:

Amongst the broader Global Network of People Living with HIV (GNP+) presence were a large number of youth at the conference who, together with many adults, some of whom have been HIV-positive for more than 20 years, made a very strong call to policymakers and programme implementers not to proceed without engaging youth, with the message “nothing about us, without us” strongly heard in both the formal plenary proceedings, satellite presentations and throughout Global Village activities. Whilst global AIDS-related deaths for all ages have fallen in recent years, adolescent deaths have risen in the same period. This draws attention to the many particular difficulties involved in caring for HIV-positive adolescents, including transitioning from paediatric care to adult HIV services.

PATA presented a poster at the AIDS 2014 conference entitled “Transitioning HIV-infected children and adolescents into adult HIV programmes: Barriers and recommendations from frontline HIV healthcare workers in sub-Saharan Africa”. The research found that programmes will not be successful unless they are able to address barriers adolescents are faced with during this transitional period, providing more adolescent-friendly and focussed services, coupled with adolescent-led engagement, care and support initiatives.

Clinical and social research:

Whilst hopes on early treatment strategies being linked to an HIV cure were dashed with the re-appearance of HIV in the well-known Mississippi Baby case, it was proposed that total viral suppression remains the next best outcome, with ongoing efforts and various successes being achieved in destroying viral particles and depleting hidden reservoirs. Research is demonstrating potential treatment modalities that could be inserted vaginally or subcutaneously that are slow releasing and long acting, offering exciting future possibilities for improved retention through decreasing pill burdens and treatment fatigue. New drug combinations are also showing positive results in being able to speed up treatment for TB even amongst drug resistant and co-infected HIV-infected patients. PrEP remained high on the agenda with an increasing acceptance of PrEP being considered within the prevention toolbox.

In the context of social research, data emerging from Zambia has found that couples voluntary counselling and testing (CVCT) can reduce HIV incidence rates within relationships, drawing attention to the significance of finding ways to include men in the response. Research conducted in South Africa by Dr Lucie Cluver from Oxford University, together with PATA as one of the partner organisations, illustrated that a range of interventions, including cash grants, school feeding and psychosocial support can reduce HIV risk behaviour by half in adolescent boys and girls. Adolescence is recognised as a time of significant physical, biological and psychological change, of rapid cognitive and social development, as well as a time of increased risk for HIV. The many social and economic pressures adolescents experience further contribute to their vulnerability and any success in shifting the current increasing prevalence and mortality rates amongst adolescent populations will require addressing these underlying drivers.

Whilst the gap between science and practise remains challenging, it would seem that greater efforts in research are being made and directed toward investigations becoming more relevant, understandable and available to the broader delegate community in a manner that can inform practise and provide transferrable implementation options.

Stigma and discrimination:

Concern and warning around discriminatory laws and policies in many countries was highlighted as setting us back and threatening progress through limiting rights, reducing health care access and fueling the epidemic further. Healthcare providers play a critical role and are at the forefront of ensuring health services are delivered without discrimination, in ways that do not exacerbate stigma but rather reinforce the dignity and rights of each and every patient. The International HIV/AIDS Alliance, in collaboration with the Coalition for Children affected by AIDS, released “Difficult Decisions”, an ethical decision-making toolkit for healthcare workers. They also provided helpful training sessions during the conference on dilemmas, decisions and ethical practice. http://www.ccaba.org/our-projects/policy/care-worker-guidance/

Key populations:

Key populations, defined as having a disproportionate risk for HIV, include people who inject drugs, men who have sex with men, transgender individuals and people who sell sex. More attention and targeted interventions are needed given that these populations’ marginalization in society exacerbates their disproportionate rates of HIV. This is concerning amidst the wave of discriminatory legislation, calls for criminalization and traditionalist policy reform taking place in the sub-Saharan Africa region. Amidst a generalised epidemic where all individuals need to be considered and where no-one should be neglected, increased and targeted attention for key populations is being called for. Importantly, children and adolescents within the context of key populations was not sufficiently considered (either as young people who inject drugs, young men who have sex with men, young transgender individuals and young people who sell sex or as children of any of these key populations). Further, given current statistics and challenges facing children and adolescents at large, it may be important to advocate that children and adolescents be considered, if not defined, as key populations.

Whilst existing and new advancements offer much hope, with no political voice or visibility, young children living with HIV continue to be neglected. Collectively, we must speak and act with and for children living with HIV to make available new, game-changing health technologies and to work together towards closing the treatment gap urgently. There can be no excuses for continuing to let children with HIV/AIDS fall by the wayside in the global fight against HIV/AIDS.

AIDS 2014: Post Conference Update and Online Resources
Whether you were able to be in person in Melbourne or not, you can find a wealth of information at your fingertips, including access to the latest developments in HIV-related programming, policy and scientific research. This includes practical information on the many online resources available through the AIDS 2014 website.Links to slides, abstracts and rapporteur reports

A full schedule of conference sessions with programme content is available here.

The AIDS 2014 Melbourne Declaration is the official declaration of AIDS 2014. The signatories and endorsers of this Declaration, affirm that non-discrimination is fundamental to an evidence-based, rights-based and gender-transformative response to HIV and effective public health programmes. Concerned citizens of the global community are urged to join in and sign the declaration at here.

Photo library

Free, high resolution photos from AIDS 2014 for use by the media and others (with appropriate credit) are available at this link.

On 17-22 July 2016, Durban (South Africa) will host the 21st International AIDS Conference (AIDS 2016). AIDS 2016 represents a tremendous opportunity to show how much progress South Africa has made in implementing and funding evidence-based prevention and treatment interventions. For more information about AIDS 2016 click here.